Healthcare Provider Details

I. General information

NPI: 1386671238
Provider Name (Legal Business Name): JONATHAN L GRANTHAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 12/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 FOUR STATES DR SUITE 1
GALENA KS
66739-4324
US

IV. Provider business mailing address

PO BOX 2546
JOPLIN MO
64803-2546
US

V. Phone/Fax

Practice location:
  • Phone: 620-783-4441
  • Fax: 620-783-4090
Mailing address:
  • Phone: 620-783-4441
  • Fax: 620-783-4090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number107822
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number0433509
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: